Provider Demographics
NPI:1902995194
Name:WALDORF, KATHLEEN ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANNE
Last Name:WALDORF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9775 SW WILSHIRE ST.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-646-0101
Mailing Address - Fax:503-350-1420
Practice Address - Street 1:9775 SW WILSHIRE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225
Practice Address - Country:US
Practice Address - Phone:503-646-0101
Practice Address - Fax:503-350-1420
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16987174400000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93-111-8189OtherTAX IDENTIFICATION